Healthcare Provider Details

I. General information

NPI: 1912496027
Provider Name (Legal Business Name): MIRIAM E GOLDBLUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 QUARRY RD
PALO ALTO CA
94304-1419
US

IV. Provider business mailing address

6401 MARYLAND DR
LOS ANGELES CA
90048-4741
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-5511
  • Fax:
Mailing address:
  • Phone: 310-936-6441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number300682
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA181469
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: